伤寒十三日不解。胸胁满而呕。日晡所发潮热。已而微利。此本柴胡证。下之而不得利。今反
利者。知医以丸药下之。非其治也。潮热者。实也。先宜小柴胡汤以解外。后以柴胡加芒硝汤以治
其里也。
此少阳经邪兼阳明内实之证。少阳病在经。故胸胁满而呕。所谓柴胡证也。下之而三字。疑衍
。凡柴胡证不得利。今反利者。知医以丸药下之。为医之误。非病之情也。潮热者。阳明之实也
。实则可下。而证兼少阳。则不可下。故先宜小柴胡以解其外。后以柴胡加芒硝汤以治其里。亦如
下条之先与小柴胡。后与大柴胡之例也。亦太阳篇移入。
尚从善云、此本柴胡证。下之而不得利。仲景谓此本柴胡证。医设以大柴胡汤下之。则表里俱
解。何至有下利之证云。
柴胡加芒硝汤方
于小柴胡汤内加芒硝六两。余根据前法服。不解更服。
太阳病。过经十余日。反二三下之。后四五日。柴胡证仍在者。先与小柴胡汤。呕不止。心下
急。郁郁微烦者。为未解也。与大柴胡汤。下之则愈。
太阳病。过经十余日。而有柴胡证。乃邪气去太阳之阳明。而复之少阳也。少阳不可下。而反
二三下之。
于法为逆。若后四五日。柴胡证仍在者。先与小柴胡汤。所谓柴胡汤病证而下之。若柴胡证不罢者
。复与柴胡是也。若服汤已。呕不止。心下急。郁郁微烦者。邪气郁滞于里。欲出不出。欲结不结。
为未解也。与大柴胡以下里热则愈。亦先表后里之意也。此条自太阳篇移入。
大柴胡汤方
柴胡（八两） 半夏（八两） 黄芩（三两） 生姜（五两） 枳实（四枚） 芍药（三两）
大枣（十二枚擘） 大黄（二两酒浸）
上八味。以水一斗二升。煮取六升。去滓。再煎取三升。温服一升。日三服。
按大柴胡有柴胡、生姜、半夏之辛而走表。黄芩、芍药、枳实、大黄之苦而入里。乃表里并治
之剂。而此云大柴胡下之者。谓病兼表里。故先与小柴胡解之。而后以大柴胡下之耳。盖分言之。
则大小柴胡各有表里。合言之。则小柴胡主表。而大柴胡主里。古人之言。当以意。逆往往如此。
伤寒病程已过十三日，病邪仍未解除。患者出现胸胁部胀满且伴有呕吐，每日傍晚时分定时发热（潮热），随后出现轻微腹泻。这原本属于小柴胡汤证（少阳经病变的典型证候）。此前医生误用泻下法治疗，本不应导致腹泻，如今反而出现腹泻，可知是医生使用了丸药进行攻下，这种治法是不正确的。傍晚定时发热，说明体内有实邪积滞。治疗上，应先给予小柴胡汤以解除在表之邪，之后再使用柴胡加芒硝汤以清治在里之实热。
这是少阳经邪气未解兼有阳明腑实内结的证候。少阳病邪在经络，所以出现胸胁胀满和呕吐，这就是所谓的柴胡证。“下之而”这三个字，怀疑是衍文（多余的文字）。凡是柴胡证通常不会出现腹泻，如今反而腹泻，可知是医生误用了丸药攻下，这是医生的失误，并非疾病本身的自然演变。傍晚定时发热，是阳明腑实的表现。虽然实证可以使用泻下法，但既然证候兼有少阳病，则不可直接峻下。因此，先宜用小柴胡汤来和解表邪，后用柴胡加芒硝汤来治理里实。这也如同下一条所述先给予小柴胡汤、后给予大柴胡汤的先例一样。此条原文是从《太阳篇》移入的。
尚从善说：这原本是小柴胡汤证，误用泻下法后却出现了腹泻。张仲景认为，如果当初医生能使用大柴胡汤进行攻下，那么表里之邪都能得到解决，怎么会留下腹泻的证候呢？
柴胡加芒硝汤方剂组成：
在小柴胡汤的基础上加入芒硝六两，其余按照前文的煎服方法服用。若病未愈，可继续服用。
太阳病，病程超过十余日，医生反而进行了两三次泻下治疗。此后过了四五日，柴胡证仍然存在的，先给予小柴胡汤。若呕吐不止，胃脘部拘急疼痛，心中烦闷不舒的，说明病邪尚未解除，应给予大柴胡汤。通过泻下里实，病即可痊愈。
太阳病，病程超过十余日，出现了柴胡证，这是因为邪气离开太阳经传入阳明，又转而进入少阳经。少阳病禁止使用泻下法，但医生反而进行了两三次泻下，这在治法上是逆乱错误的。如果在四五日后，柴胡证仍然存在，应先给予小柴胡汤。这就是所谓“对于柴胡汤证误用泻下法，如果柴胡证没有消除，再次给予柴胡汤”的原则。如果服药后，呕吐不止，胃脘部拘急，心中烦闷，说明邪气郁滞于体内，想排出排不出，想结聚又未完全结聚，属于病未解除。此时应给予大柴胡汤以泻除在里的热邪，病即可痊愈。这也体现了先解表后治里的意思。此条原文也是从《太阳篇》移入的。
大柴胡汤方剂组成：
柴胡（八两）、半夏（八两）、黄芩（三两）、生姜（五两）、枳实（四枚）、芍药（三两）、大枣（十二枚，掰开）、大黄（二两，酒浸）
以上八味药，用水一斗二升，煮取六升药液，去掉药渣，再煎煮浓缩至三升。每次温服一升，每日服用三次。
按语：大柴胡汤中含有柴胡、生姜、半夏等辛散药物以走表，以及黄芩、芍药、枳实、大黄等苦寒药物以入里，是一个表里双解的方剂。文中说大柴胡汤用于“下之”，是指病情兼有表里，所以先给予小柴胡汤解表，然后再用大柴胡汤攻下里实。分开来说，大小柴胡汤都兼顾表里；合起来说，小柴胡汤主要主表，而大柴胡汤主要主里。古人的言论，应当用心意去推究，往往就是这样的。
Taiyang disease (Disease of the Taiyang/Bladder channel) has persisted for thirteen days without resolution. The patient presents with fullness and distension in the chest and hypochondrium accompanied by vomiting, tidal fever (fever that peaks at a specific time, typically late afternoon) occurring daily around dusk, followed by slight diarrhea. This originally belonged to the Shaoyang pattern (a syndrome characteristic of the Shaoyang/Gallbladder channel). Previously, the physician mistakenly applied purgation therapy; since purgation should not have induced diarrhea in this context, the subsequent occurrence of diarrhea indicates that the physician used pill-based purgatives, which was an incorrect treatment method. Tidal fever indicates the presence of internal excess accumulation. Therapeutically, one should first administer Xiao Chai Hu Tang (Minor Bupleurum Decoction) to resolve the exterior pathogenic factor, and subsequently use Chai Hu Jia Mang Xiao Tang (Bupleurum Decoction with Natrii Sulfas) to treat the interior excess heat.
This is a syndrome where Shaoyang channel pathogen remains unresolved, complicated by Yangming interior excess (internal solidification). Since the Shaoyang pathogen resides in the channels, it manifests as chest/hypochondriac fullness and vomiting, known as the "Chai Hu pattern." The phrase "after purgation" is suspected to be a textual error (interpolated text). Typically, Chai Hu patterns do not present with diarrhea; the current occurrence suggests the physician erroneously used pill-purgatives, representing medical error rather than the natural progression of the disease. Tidal fever signifies Yangming excess. Although excess syndromes are amenable to purgation, the concurrent Shaoyang involvement contraindicates direct harsh purgation. Therefore, one should initially use Xiao Chai Hu Tang to harmonize the exterior, followed by Chai Hu Jia Mang Xiao Tang to address the interior excess. This follows the precedent mentioned in the next paragraph: first giving Xiao Chai Hu Tang, then Da Chai Hu Tang. This clause was transferred from the *Taiyang Chapter*.
Shang Congshan stated: This was originally a Chai Hu pattern. After erroneous purgation, diarrhea occurred. Zhang Zhongjing noted that if the physician had initially used Da Chai Hu Tang (Major Bupleurum Decoction) for purgation, both exterior and interior pathogens would have been resolved, preventing such diarrhea.
Formula: Chai Hu Jia Mang Xiao Tang (Bupleurum Decoction with Natrii Sulfas)
Add six liang of Mang Xiao (Natrii Sulfas, Mirabilite) to Xiao Chai Hu Tang (Minor Bupleurum Decoction). Prepare and administer according to the previous method. If symptoms persist, continue administration.
In Taiyang disease, after more than ten days, the physician incorrectly performed purgation two or three times. Four or five days later, if the Chai Hu pattern persists, administer Xiao Chai Hu Tang (Minor Bupleurum Decoction) first. If vomiting continues incessantly, there is urgency and tension in the epigastrium, and the patient feels郁郁微烦 (internally constrained and slightly vexed), indicating the disease is not yet resolved. Administer Da Chai Hu Tang (Major Bupleurum Decoction); purging the interior will lead to recovery.
When Taiyang disease persists beyond ten days and Chai Hu patterns emerge, it indicates the pathogen has left the Taiyang channel, entered the Yangming, and then shifted to the Shaoyang channel. Shaoyang disorders contraindicate purgation, yet the physician purged two or three times, which is therapeutically adverse. If four or five days later the Chai Hu pattern remains, administer Xiao Chai Hu Tang (Minor Bupleurum Decoction) first. This aligns with the principle: "If purgation is wrongly applied to a Chai Hu pattern, and the pattern persists, re-administer Chai Hu [formulas]." If, after taking the decoction, vomiting persists, epigastric urgency occurs, and internal constraint/vexation arises, it indicates pathogen stagnation in the interior—unable to exit, unable to fully consolidate—signifying unresolved disease. Administer Da Chai Hu Tang (Major Bupleurum Decoction) to purge interior heat, leading to recovery. This also reflects the principle of treating the exterior before the interior. This clause was also transferred from the *Taiyang Chapter*.
Formula: Da Chai Hu Tang (Major Bupleurum Decoction)
Chai Hu (Radix Bupleuri, 8 liang), Ban Xia (Rhizoma Pinelliae Preparatum, 8 liang), Huang Qin (Radix Scutellariae, 3 liang), Sheng Jiang (Rhizoma Zingiberis Recens, 5 liang), Zhi Shi (Fructus Aurantii Immaturus, 4 pieces), Shao Yao (Radix Paeoniae Alba, 3 liang), Da Zao (Fructus Jujubae, 12 pieces, split), Da Huang (Radix et Rhizoma Rhei, 2 liang, soaked in wine).
Take the above eight ingredients, boil in 12 sheng of water, reduce to 6 sheng, remove dregs, and further decoct to obtain 3 sheng. Warm and take 1 sheng per dose, three times daily.
Commentary: Da Chai Hu Tang (Major Bupleurum Decoction) contains acrid-warm herbs like Chai Hu, Sheng Jiang, and Ban Xia to disperse the exterior, and bitter-cold herbs like Huang Qin, Shao Yao, Zhi Shi, and Da Huang to enter the interior, making it a formula that treats both exterior and interior simultaneously. When the text states Da Chai Hu Tang is used for "purging," it implies that because the disease involves both exterior and interior, one first uses Xiao Chai Hu Tang (Minor Bupleurum Decoction) to resolve the exterior, then uses Da Chai Hu Tang to purge the interior. Separately considered, both Minor and Major Bupleurum formulas address both levels; collectively, Xiao Chai Hu Tang primarily addresses the exterior, while Da Chai Hu Tang primarily addresses the interior. Ancient texts require interpretation through contextual understanding, which is often the case here.